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ti i � <br /> . � w <br /> i ?f�3 <br /> � 'i3*-.�j`� <br /> ; <br /> a �,� j� }1 CITY Of �1RON� <br /> �. ¢ _ <br /> r; <br /> � .� <br /> �" �, +;.•;- ' Post Office Box 66•Crystal Bay, Minnesota 55323•Municipal Offices <br /> ,� <br /> J„3. i ~kr��� �h:: ;`• <br /> r � <���� , � . On the North Shore of Lake Minnetonka <br /> DATA PRIVACY ADVISORY <br /> In accordance with M.S. 13.04 , Subd. 2 , "Rights of subjects o£ <br /> data" , we would Iike to inform you that your request for a permit or <br /> Iicense from the City of Orono or any of its departments may require <br /> you to furnish certain private or confidential information. <br /> You are notified that: <br /> l. The information you furnish will be used to determine your <br /> qualification for the permit or Iicense requested. <br /> 2. You may refuse to supply data, but refusal may require that <br /> the City deny the permit ar license. <br /> 3. The information may be shared with other �ocal , state or <br /> federal agencies to the extent necessary to grocess the permit or <br /> license. <br /> 4. If your requested permit or Iicense requires Councyi. action <br /> to approve, some information may become public. <br /> 5. You have certain rights under M.S. 13.04 Lo review prica�� <br /> data on yourself. <br /> 6. Your full naMe is required to process this apFlicatica or <br /> permit. <br /> �� �;�xCll �07�,��u� _ <br /> �l��� Middle Last <br /> First <br /> 21(�� C�i�� ��rw1�Q�,� <br /> Address <br /> ��C ;1Gti �`1, �7>� � <br /> City State Zip <br /> 3�V1 �� �-� 11 <br /> Phone <br /> I understand my rights as stated above. <br /> � %" �� <br /> C <br /> Signature <br /> BUILDING&ZONING—473-7357 • ADMINISTRATION&FItiANCE —473-7358 • PUBLIC WORKS—473-�359 <br /> ASSESSING <br />